HB 301-AUTOPSIES AND DEATH CERTIFICATES  3:04:56 PM CHAIR HIGGINS announced that the first order of business would be HOUSE BILL NO. 301, "An Act relating to duties and procedures of the state medical examiner and the Department of Health and Social Services; and relating to death certificates." 3:05:35 PM REPRESENTATIVE BOB HERRON, Alaska State Legislature, introduced HB 301, as the sponsor of the bill, and paraphrased from the sponsor statement: Each year, around the state, Alaskan families suffer the unexpected loss of a loved one. Accidental death is common in the course of work, play, and providing food for the family table. Each loss is critical. Each family's grief is real. For many rural Alaskans, the natural grieving process is further complicated by the fact that their deceased loved ones' remains must be shipped into Anchorage, at State expense, for review by the State Medical Examiner (ME) in order to establish a cause of death and obtain the death certificate required for legal burial. On top of staggering loss and major life changes comes the stress of more forms, more requirements, and more confusion in a process that is already difficult to navigate. In many cases families have, without the knowledge required to make fully informed choices, agreed to the use of expensive funeral home services - and then found themselves on the hook for thousands of dollars they do not have but must somehow pay before the funeral homes will allow their loved ones' remains to return home. At the same time, the State of Alaska currently spends General Fund dollars to transport remains of individuals to and from Anchorage, when existing technology in many regions could be used to reduce the number of transports required. HB 301 seeks to make minor changes to the law guiding the Alaska Department of Health and Social Services' current autopsy and death certificate issuance process. Recognizing that good people oversee and perform the work addressed in this bill, HB 301 approaches each change with an eye for treating grieving Alaskans with greater compassion, maximizing the use of quality existing resources, and saving state funds - all while continuing to meet legal obligations and ensuring the ME's office retains the support and resources it needs to do the job right. REPRESENTATIVE HERRON explained that he was working with local non-profit organizations in the Bethel region to hire a navigator, who would help a family with advice on how to deal with the medical examiner and the funeral home. He reported that the fiscal note for $5,000 [a one-time cost to purchase and install the necessary telemedicine/video conferencing technology at the Medical Examiner's office] would save the state money, as it would allow for a remote post mortem examination, and decrease the costs for transportation of bodies to Anchorage for examination. 3:11:37 PM CHAIR HIGGINS asked for the bullet points to the proposed changes resulting from HB 301. 3:12:14 PM LIZ CLEMENT, Staff, Representative Bob Herron, Alaska State Legislature, directing attention to the Sectional Summary for HB 301 [Included in members' packets], reported that Section 1 amended AS 12.65.025(a)(2) and replaced "may" with "shall." She explained that this allowed the State Medical Examiner (ME) to ship the body to a community chosen by the family. REPRESENTATIVE HERRON offered an anecdote for the shipment of bodies, noting that the proposed bill would sometimes result in a savings for the state. MS. CLEMENT stated that this would require the ME to ship the body wherever requested, as long as there was not any additional cost to the State of Alaska. She lauded the practice of the current ME, noting that this proposed bill would ensure these current practices beyond the tenure of the current ME. 3:16:43 PM MS. CLEMENT explained an additional change in Section 1 of the proposed bill which amended AS 12.65.025(a)(3). She stated that embalming was not required by law, although it had previously been, and this change would clarify it. She reported that some air carriers mistakenly believed that embalming was always required prior to transportation. CHAIR HIGGINS asked for clarification regarding embalming by a transporting entity. He asked whether a requirement by the transporter for embalming would necessitate embalming by the state prior to transport. MS. CLEMENT replied that the state would then be financially responsible for the embalming. In response to Chair Higgins, she expressed agreement that this was new language. REPRESENTATIVE HERRON, in response to Chair Higgins, said that embalming had not been an issue in the past and that the language had been added to the proposed bill as an "extra pair of suspenders." REPRESENTATIVE TARR, noting the difference between the fiscal notes in the House and Senate versions of HB 301, asked if there was a mechanism for the state to pay for the transportation if the family could not afford to pay the cost difference to the requested final destination. REPRESENTATIVE HERRON expressed his support for the position by the State of Alaska to pay for the return of a body, but not to incur any additional expense. He declared that this was "a fairness issue." REPRESENTATIVE TARR asked about a situation where the family could not afford to bring the body to a chosen place. REPRESENTATIVE HERRON replied that the state did work with the families, and he stressed the value for the assistance of a navigator in a regional hub. MS. CLEMENT directed attention to Section 2, which primarily allowed the state the flexibility to consider working with high quality, existing infrastructure in Rural Alaska. She pointed out that the Alaska Tribal Health System (ATHS) had done "a phenomenal job over the last years investing in tele-health and tele-medicine equipment that allows them to do tremendous things by a distance delivery." She acknowledged that the proposed bill would allow Department of Health and Social Services (DHSS) to work with ATHS and utilize the existing technology and resources in the region. She offered an example for its use to save time, money, and stress. 3:24:04 PM MS. CLEMENT pointed out that Section 2 [subsection (g)] outlined standards for fair, respectful written communication between the ME's office and surviving family members. She reported that the ME forms had been edited, that the proposed bill outlined the necessary information for disclosure, and that it must be offered "in a non-threatening and non-coercive manner." 3:25:05 PM MS. CLEMENT directed attention to Section 2, [subsection] (h), which added a standard practice into statute. She explained that, currently, it was standard practice for the ME's office to freeze the body as this was the best means of preservation for transport. REPRESENTATIVE HERRON reported that the ME had agreed as this was a humane practice. He lauded the efforts by the air carriers to return the remains. CHAIR HIGGINS asked if [subsection] (h) was new. REPRESENTATIVE HERRON replied that this was already the normal practice. 3:27:04 PM REPRESENTATIVE KELLER directed attention to page 2, lines 22-24, and asked for clarification to the meaning for "otherwise." REPRESENTATIVE HERRON explained that this offered the family the option of sending the body to a funeral home, whereas previous language had seemingly required that the body be sent to a funeral home. REPRESENTATIVE KELLER expressed his support for the clarity. REPRESENTATIVE HERRON declared that it was necessary for a transparent process during a time of grief, without any decisions being forced on the family. 3:30:13 PM CHAIR HIGGINS directed attention to page 2, line 3, and expressed his discomfort with giving the decision for embalming to the transporting entity. REPRESENTATIVE KELLER asked if deleting the phrase "or by a policy of the transporting entity" on page 2, line 3, would harm the proposed bill. REPRESENTATIVE HERRON deferred to the DHSS. REPRESENTATIVE SEATON asked whether page 2, line 29, offered a choice of location or demanded the destination. MS. CLEMENT, in response, referred to page 2, line 19, which stated that "the notice must explain, in a form and language that is designed to be easy to understand, the availability of transportation to another location." She offered her belief that this allowed a choice of destination to the family, other than the place of death. REPRESENTATIVE SEATON mused that the proposed bill suggested that the body would be sent to a different location, which could result in confusion. REPRESENTATIVE HERRON offered to discuss this with the drafter of the bill. 3:34:29 PM MS. CLEMENT moved on to discuss Sections 3, 4, and 5 of the proposed bill, which amended AS 18.50 "to facilitate the declaration of death and issuance of a death certificate in- region for cases in which transport to the Medical Examiner's office is deemed unnecessary." She reported that part of the process when bodies were shipped to the ME's office was to establish a legal cause of death, which allowed a death certificate to be filed, issued, and shared with the family. She pointed out that, as bodies need a death certificate regardless of a review by the ME's office in Anchorage, this would provide DHSS the flexibility to work with entities in Rural Alaska for issuance of a death certificate. REPRESENTATIVE HERRON reported that the navigator in the Bethel region had assisted families for almost 20 years, without any funding from the state. He suggested that the regional hubs, which provided social services, could continue to help families, and this proposal would put that in statute. 3:36:21 PM MS. CLEMENT moved on to Section 6, which added a new subsection (e) to AS 18.50.280. This would put into statute the current practice by the ME's office for obtaining the Burial Transit Permit to move the dead body. REPRESENTATIVE HERRON exampled that, when a family agreed to embalm and to buy casket, there was a significant taxi fee due when the body was moved from the ME's office to the funeral home, and then to the airport. 3:38:15 PM CHAIR HIGGINS asked about the use of "fetus" on page 3, line 21, and asked if this should be used in addition to "body" in other places in the proposed bill. REPRESENTATIVE HERRON offered his belief that it was conforming language. REPRESENTATIVE SEATON, asking about the proposed modifications on page 2, line 1, questioned whether these provisions would be eliminated and asked for clarification regarding the cremation and internment option in AS 12.65.025. REPRESENTATIVE HERRON replied that it was not changing. CHAIR HIGGINS asked about the embalming requirement on page 2, line 3, and asked if removal of the aforementioned clause would affect the bill. KERRE SHELTON, Director, Alaska Division of Public Health, Department of Health and Social Services, said that there was not any known policy by any transport companies which required embalming. She said that the ME routinely shipped bodies throughout Alaska using a variety of air carriers, and none had required that a body be embalmed prior to shipping after the post-mortem examination. CHAIR HIGGINS asked if a body was lighter after embalming. MS. SHELTON replied that embalming did not affect the body weight. REPRESENTATIVE KELLER asked about the indeterminate costs in the fiscal note and asked for any guidance for parameters. MS. SHELTON expressed her agreement that there were some indeterminate costs in the fiscal note. She clarified that there was no current policy for transporting entities to require embalming. However, she pointed out, should the proposed bill pass, and if one or all of the transporting entities decided to implement an embalming policy, then the state would be required to pay for the embalming. She reported that the state did not have embalming facilities, and the contract cost with a local funeral home was about $1,000 per body. This would also prolong the time period for return of the body to the family. She noted that the ME did not have the capability to maintain temperature, although freezing the body was an option in some circumstances. She pointed out that there was no way to predict the costs for enforcing temperature controls. She said that the rural communities had made excellent use of the telemedicine equipment for rural examinations; however, there would also be a requirement for any medical, legal, forensic investigation to have certain infrastructure for a proper examination and level of care, which would include floor drains, exam tables, proper radiology, storage, specimen collection abilities, body scales, and body washing equipment. She declared that a manipulatible HD camera was also necessary to deliver an accurate picture to the forensic pathologist in Anchorage, and this would be a cost to the community. She noted that the ME office would also need to purchase telemedicine equipment to view the incoming information. 3:48:46 PM REPRESENTATIVE HERRON said that telemedicine equipment was already proven. He stated that the ideal situation was for transport of a body to the regional hub where a doctor could utilize the equipment and communicate with the ME, instead of asking a state trooper on-site to describe the injuries and the possible cause of death. He expressed his agreement that the right equipment was necessary, and that technology could decrease the cost and the times for dealing with these situations. He suggested that the ME office buy the necessary equipment to interface with every major hub in the state. 3:50:47 PM REPRESENTATIVE SEATON asked if the section on embalming should be removed as it was not required. REPRESENTATIVE HERRON replied that this was a technical question for which he would seek the advice of others. CHAIR HIGGINS, pointing to page 3, line 2, questioned whether it was necessary for the state to provide temperature controlled transport. MS. SHELTON replied that the proposed bill did require temperature and other controls, pointing out that the ME did not have any means of control other than freezing the bodies. She was not able to offer any cost estimate for this. REPRESENTATIVE HERRON relayed that although the testimony stated that the department did not currently have those controls, once available, it would be humane to use them. CHAIR HIGGINS expressed his agreement, and offered his belief that "the question boils down to what's the cost for us to do this." REPRESENTATIVE HERRON suggested that people could testify for the success over the past years. 3:53:59 PM REPRESENTATIVE KELLER offered his belief that three things were being committed to in the proposed bill for which the state had no control. He pointed out that the state did not set the standards for "shall provide for temperature and other controls available to maintain the body," so that someone else would make that determination. He declared that this was the same issue with transportation costs, as the state had no control for the embalming. He stated that any cost for cosmetology would also be set by the entity. He asked to hear from the drafter for help to identify these issues. REPRESENTATIVE HERRON offered his belief that it was not necessary, but he wanted discussion by many people for "the right thing to do." REPRESENTATIVE KELLER asked who Representative Herron would recommend to include in the conversation. REPRESENTATIVE HERRON declared his desire for inclusion of testimony on the historic reality. He stated that, should a family choose to embalm, they are now aware that they have to pay for this. He stated his desire that the proposed legislation would change the perception that the state was dictating the family decisions. He expressed his desire to not focus on the embalming, but to allow this to be a request by the families. REPRESENTATIVE KELLER noted that the House Health and Social Services Standing Committee was the only committee of referral. REPRESENTATIVE HERRON pointed out that, as there was a fiscal note, it would also be heard by the House Finance Committee. 3:58:00 PM REPRESENTATIVE SEATON asked if air carriers were the only means of transportation used by the Medical Examiner. REPRESENTATIVE HERRON replied that this was the quickest means, and was most often requested by the family, although the body could sometimes be delivered by the road system. 3:59:14 PM CHAIR HIGGINS opened public testimony. 3:59:25 PM RAEBELLE WHITCOMB, Director, Workforce Development Center, Bristol Bay Native Corporation, shared that they offered burial assistance and they worked directly with the state and with grieving families. Referring to AS 12.65.025(a)(3), she declared that embalming was required by law. She reported that they received 30 - 40 annual requests for services by tribal community members. She acknowledged that costs had increased dramatically, and that individuals without any resources would contact DHSS. She stated that funeral homes were able to leverage the services, noting that the cost of one way transport from the ME office to the funeral home was $500. If the state did not pay this cost, then the family or the tribe had to pay. She stated that their burial assistance services were capped at $2500, and any overages were not paid back by the federal government for two years. She said that embalming had cultural and religious concerns, and that these containers incurred additional special handling charges by the air carriers. She reported that a funeral home would charge for any restoration after traumatic injuries, as well as for dressing, casketing, and cosmetology. She declared that costs were rapidly increasing. She reported that, as the ME had stated that the body would not be washed, the family felt obligated to use these additional services. She stated that it was always a struggle between the ME and the DHSS for who would pay for which costs. She pointed out that many families did not understand the process. The cost for embalming was expensive, and during a grieving period, the families were not thinking about the total costs. She questioned the impact of embalming fluid on the soil, noting that many cemeteries were in tidal waters, and reported that embalming was not part of traditional use. She shared some personal anecdotes regarding airlines and this requirement for embalming. She declared that airlines believed that embalming was required by state law. She suggested that tribal communities should be used as a resource during the death process. She questioned the relationship between the Code of Criminal Procedure and the Alaska Statutes, as the two differed on the requirements for embalming and transportation. She stated that there must be weight changes after embalming, as there had always been additional charges, and those charges were required to be paid prior to any release of the body. She questioned the need for restoration after a traumatic injury, and any ensuing charges. She declared that the proposed bill was important, but required further discussion. She asked that the larger issues regarding embalming and the protocol be considered before being removed. 4:10:36 PM REPRESENTATIVE SEATON asked which state trooper policies were in contraindication regarding embalming. MS. WHITCOMB directed attention to AS 12.65, the Code of Criminal Procedure. REPRESENTATIVE SEATON asked if she was referencing AS 12.65.025, which addressed embalming required by law. In response to Ms. Whitcomb, he asked for clarification that if this was not required by the law, then it should be removed from the proposed bill so that the Alaska State Troopers were not confused. MS. WHITCOMB replied that there was not any confusion among the troopers, the family, and the airlines, as this was the practice when bodies were transported. She reported that some airline agents had allowed the bodies to be transported when not embalmed, but there were also incidences when transportation had been blocked. She said that the larger commercial air freight transporters would use their freezer capabilities in lieu of embalming. She offered anecdotes for other means of transportation for bodies. 4:13:41 PM JACKIE RUSSELL, Social Worker, Bristol Bay Area Health Corporation Hospital, stated her support for the proposed bill declaring that its impact on the families would be positive. She said that families often called the hospital and the village tribal council for assistance and financial support. She offered her belief that embalming was unusual, as most requests by families were for the traditional ways. She questioned the additional cost for tele medicine. She suggested that the hospital staff would cooperate in support. She concluded that, as she was not in support of adding more costs or moving in contradiction to family beliefs and culture, she endorsed the proposed bill. 4:16:56 PM NICHOLAS HOOVER, Director, Social Services, Association of Village Council Presidents (AVCP), declared support by AVCP for proposed HB 310. He reported that AVCP represented 56 federally recognized Indian tribes in the Yukon-Kuskokwim Delta, within a region the size of the State of Oregon, none of which were connected by road. He relayed that the area had the highest unemployment rate and lowest per capita income in Alaska, and that AVCP provided social services to more than 38 households annually. He shared that burial assistance, a monetary contribution toward burial expenses, was a program that AVCP provided. He reported that tribal members often complained about the difficulty of the state process, which included issuance of a death certificate only after its authorization, and required transportation of the deceased to Anchorage for autopsy. As families were not aware of the many services in Anchorage, they often incurred costs that were not necessary and were often informed that the deceased would not be released until payment was made in full. He reported that the costs for any additional weight from either embalming or a casket were the responsibility of the family, and he noted that few families had these extra funds for transportation. He stated that multiple calls by AVCP to the Medical Examiner to discuss alternatives and resolution of these issues had not been returned. He reported that a resolution was passed at the annual AVCP convention in October, 2010, declaring this current system to be a problem for Rural Alaska Natives. He relayed that subsequent calls to the ME office the following year were still not returned. He declared that AVCP fully supported the proposed bill, as it would "provide a much needed fix and reduce the unnecessary stress placed upon our grieving families." 4:22:55 PM MARCIA DAVIS, General Council, Senior Vice President, Calista Corporation, informed the committee that she had been very involved with the drafting of the language for the proposed bill. She shared that she had worked with the ME office to discuss the policy issues. She stated that this was "an opportunity to lower the overall transactional costs of these deaths." She reported that an accidental death or a suicide would set a chain of events in-motion, and the body almost always went to the Anchorage ME office to ensure that no crime had been committed. The ME office, with its alignment toward a law enforcement mission, believed that Rural Alaska deserved the same level of justice as urban Alaska. She reported that any evidence acquired during autopsies would have evidentiary status, and was provable in court. She opined that only one of the last 5000 deaths in Rural Alaska had posed an intricate staged suicide or some staged accidental death, and declared that most rural deaths were "plain and simple. They come generally from either truly difficult lifestyles... or they come from hopelessness and substance abuse." She explained that the families were ill-equipped to deal with the original [Medical Examiner] forms, as "unfortunately, it was culturally tone deaf." She shared that the tradition in Rural Alaska was for the body to be washed by someone of the same gender, staged at the family home, and then friends and family come to share food and remembrances. The custom was, after three days, for the body to be buried. When the body was sent to the ME, the family was given a form which required the determination of who would pick up the body. The language of the form relayed a different connotation to Rural Alaskans, creating confusion, without any disclosure for the costs involved. Most of the time, the families signed the forms without fully understanding the implications, and this failure of communication resulted in "huge sums of money that have been shifted toward a system that isn't needed." She emphasized that the families did not need caskets, or embalming, and simply needed the bodies sent back quickly once the ME had finished. She lauded the proposed bill as it restored a balance to the communication by ensuring clarity on the forms. She reported that the language of the form was still being determined, and once it was finished, the form would be translated into Yupik and other regional languages. She said that navigators would also be available for family guidance. Directing attention to the legal requirement for embalming, she pointed out that the proposed bill also allowed for policy by the transporting entity. She shared that, as there was a burden to convince the transportation companies that embalming was no longer required by law, hence the language. She expressed her confidence that the ME office could better convince an air carrier that the embalming was no longer required than could a family in Rural Alaska, as the proposed bill offered the ME office statutory cover. She stressed that the family should not have to pay the additional cost for embalming, and that the State of Alaska was in the best position to ensure that there were not any additional costs. 4:31:36 PM REPRESENTATIVE SEATON, directing attention to page 2, line 3, suggested removal of "by law or", which would indicate that embalming was only required by a policy of the transporting company. MS. DAVIS replied that retaining the "by law" would allow coverage should any circumstance arise whereby bodies were dangerous unless embalmed. She declared that, should embalming remain required as a matter of law, the extra cost should be paid by the ME, not the family. She emphasized that any costs incurred while the ME had custody of the body, doing the business of the state, should be paid by the state. The family should only incur the costs which would have otherwise been incurred. REPRESENTATIVE SEATON expressed his desire for clarification to the transporting agencies and the state troopers. MS. DAVIS pointed out that he was addressing the "inherent ambiguity of the current existing language, and that could be corrected by saying embalming if required by law." REPRESENTATIVE KELLER confirmed that there was a problem for expanded risk for cost if an air carrier was making the determination. MS. DAVIS suggested that the language could be deleted. She explained that it was necessary for the ME office and the state to fully understand that the body in custody was their responsibility until it was returned to its home. If there was a situation where an air carrier had changed a policy or created a problem, this would still be included with the state's burden for return transportation. She wanted cost and duty to be co- extensive, with an acknowledgement that no family would be left "figuring out how to get a body back." She mentioned that the current law stated that cosmetology was only required to make the head, face, neck, and hands presentable if those parts had been disfigured by the post mortem examination. She opined that the concern expressed in the fiscal note reflected a need for definition to the level of contract work performed in the rural areas. She offered her belief that the proposed bill gave the ME office latitude to step into the use of technology, as "the State Medical Examiner shall designate a location if a facility with adequate technology and personnel is available." This would allow a judgment call by the ME office to determine adequacy on a case by case basis, dependent on the circumstances. In the state regions, the technology of each agency would be able to evolve. She did not immediately foresee "full-on autopsies out in the region." 4:37:37 PM MS. DAVIS reported that the ME office did a great job of controlling the temperature for bodies. MS. DAVIS, in response to Representative Keller, explained that the current cosmetology law was listed on page 2, lines 5-7. She directed further attention to page 2, lines 9-12, regarding the location for post mortem examinations and the adequate facility. REPRESENTATIVE SEATON asked for clarification that the department shall provide for the current temperature control practices, which could include dry ice, during transport. MS. DAVIS replied that, as the ME office was humane and kind, and made efforts to do the right thing, the proposed bill offered "cover" for the ME office to continue these efforts. REPRESENTATIVE TARR asked if the problem could be mitigated with an additional ME office in either Fairbanks, or closer to many rural communities. MS. DAVIS offered her belief that the ME office had a satellite office in Fairbanks, which shouldered some of the work load. She projected an evolution of the relationship between the ME office and the local health care providers resulting in regional offices. REPRESENTATIVE TARR asked for clarification that there was only one ME. MS. DAVIS expressed her agreement and said that this standard was the same in many similarly populated states. 4:42:04 PM The committee took a brief at-ease. 4:42:43 PM CHAIR HIGGINS stated that HB 301 would be held over and public testimony would be left open.